JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO.

17, 2019

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PUBLISHED BY ELSEVIER. ALL RIGHTS RESERVED.

STATE-OF-THE-ART REVIEW

Update on Cardiac Catheterization in

Patients With Prior Coronary Artery
Bypass Graft Surgery
Iosif Xenogiannis, MD,a,b Peter Tajti, MD,a,b,c Allison B. Hall, MD,a Khaldoon Alaswad, MD,d Stéphane Rinfret, MD,e
William Nicholson, MD,f Dimitri Karmpaliotis, MD,g Kambis Mashayekhi, MD,h Sergey Furkalo, MD,i
João L. Cavalcante, MD,a M. Nicholas Burke, MD,a Emmanouil S. Brilakis, MD, PHDa,b

JACC: CARDIOVASCULAR INTERVENTIONS CME/MOC/ECME

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CME/MOC/ECME Objective for This Article: Upon completion, the reader
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prior CABG; 2) evaluate strategies to prevent and treat distal emboli-
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4) identify the optimal treatment strategy for acute graft failure;

The American College of Cardiology Foundation (ACCF) is accredited by 5) select the optimal method of revascularization in patients with prior

the Accreditation Council for Continuing Medical Education to provide CABG; and 6) decide between native vessel versus graft PCI in prior

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Author Disclosures: Dr. Alaswad has received consulting fees from Ter-
umo and Boston Scientific; and has been an unpaid consultant for
Abbott Laboratories. Dr. Rinfret has received speaker and proctorship
honoraria from Boston Scientific, Abbott Vascular Canada, Medtronic
Canada, SoundBite, and Terumo US. Dr. Nicholson has been a proctor,
consultant, and advisory board member for Abbott Vascular, Boston
Scientific, and Medtronic. Dr. Karmpaliotis has received speaker hono-
raria from Abbott Vascular and Boston Scientific. Dr. Mashayekhi has
received consulting/speaker fees from Ashai Intecc, AstraZeneca, Bio-
tronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic,
Teleflex, and Terumo. Dr. Cavalcante has received research grants from
Medtronic and Abbott; and has been a consultant/speaker for Med-
tronic, Circle Cardiovascular Imaging, and Siemens Inc. Dr. Burke has
received consulting and speaker honoraria from Abbott Vascular and
Boston Scientific. Dr. Brilakis has received consulting/speaker honoraria
from Abbott Vascular, American Heart Association (associate editor:
Circulation), Boston Scientific, Cardiovascular Innovations Foundation
(board of directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Med-
tronic; has received research support from Regeneron and Siemens; is a

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1636 Xenogiannis et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019

Cardiac Catheterization in Prior CABG Patients SEPTEMBER 9, 2019:1635–49

Update on Cardiac Catheterization in

Patients With Prior Coronary Artery
Bypass Graft Surgery
Iosif Xenogiannis, MD,a,b Peter Tajti, MD,a,b,c Allison B. Hall, MD,a Khaldoon Alaswad, MD,d Stéphane Rinfret, MD,e
William Nicholson, MD,f Dimitri Karmpaliotis, MD,g Kambis Mashayekhi, MD,h Sergey Furkalo, MD,i
João L. Cavalcante, MD,a M. Nicholas Burke, MD,a Emmanouil S. Brilakis, MD, PHDa,b

ABSTRACT

Patients who undergo coronary bypass graft surgery often require subsequent cardiac catheterization and repeat coro-
nary revascularization. Saphenous vein graft lesions have high rates for distal embolization that can be reduced with use
of embolic protection devices. They also have high restenosis rates, which are similar with drug-eluting and bare-metal
stents. Percutaneous coronary interventions of native coronary arteries is generally preferred over saphenous vein graft
interventions, but can often be complex, requiring expertise and specialized equipment. Prolonged dual-antiplatelet
therapy and close monitoring can help optimize subsequent clinical outcomes. (J Am Coll Cardiol Intv 2019;12:1635–49)
© 2019 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

P atients who undergo coronary artery bypass

graft surgery (CABG) often require additional
revascularization because of bypass graft
failure or progression of native coronary artery dis-
provide an overview of novel developments in car-
diac catheterization and PCI in prior CABG patients,
as well
Illustration).
as practical recommendations (Central

ease (Figure 1) (1,2). Due to the high risk of redo

CABG, coronary revascularization is performed by
percutaneous coronary intervention (PCI) in nearly
all prior CABG patients, but is associated with
several challenges, both clinical (high-risk patient
characteristics) and technical (such as treatment
of failing bypass grafts, chronic total occlusions
[CTOs], and severe calcification). We sought to
ACCESS SITE SELECTION
Engagement of arterial grafts and saphenous vein
grafts (SVGs) for angiography and/or PCI can be per-
formed using either femoral or radial approach,
however femoral access is associated with lower
contrast and radiation dose (3). Although systematic

From the aMinneapolis Heart Institute, Abbott Northwestern Hospital, Center for Complex Coronary Interventions, Minneapolis,
Minnesota; bMinneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Complex Coronary Artery Disease Science
Center, Minneapolis, Minnesota; cUniveristy of Szeged, Department of Invasive Cardiology, Second Department of Internal
Medicine and Cardiology Center, Szeged, Hungary; dHenry Ford Hospital, Department of Interventional Cardiology, Detroit,
Michigan; eMcGill University Health Centre, McGill University, Department of Interventional Cardiology, Montreal, Quebec,
Canada; fWellSpan Cardiology, Department of Interventional Cardiology, York, Pennsylvania; gColumbia University Medical
Center, Center for Interventional Vascular Therapy, New York, New York; hDepartment of Cardiology and Angiology II University
Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany; and the iDepartment of Endovascular Surgery and Angiography,
National Institute of Surgery and Transplantology of AMS of Ukraine, Kiev, Ukraine. Dr. Alaswad has received consulting fees from
Terumo and Boston Scientific; and has been an unpaid consultant for Abbott Laboratories. Dr. Rinfret has received speaker and
proctorship honoraria from Boston Scientific, Abbott Vascular Canada, Medtronic Canada, SoundBite, and Terumo US.
Dr. Nicholson has been a proctor, consultant, and advisory board member for Abbott Vascular, Boston Scientific, and Medtronic.
Dr. Karmpaliotis has received speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Mashayekhi has received
consulting/speaker fees from Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi-Sankyo, Medtronic,
Teleflex, and Terumo. Dr. Cavalcante has received research grants from Medtronic and Abbott; and has been a consultant/speaker
for Medtronic, Circle Cardiovascular Imaging, and Siemens Inc. Dr. Burke has received consulting and speaker honoraria from
Abbott Vascular and Boston Scientific. Dr. Brilakis has received consulting/speaker honoraria from Abbott Vascular, American
Heart Association (associate editor: Circulation), Boston Scientific, Cardiovascular Innovations Foundation (board of directors),
CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; has received research support from Regeneron and Siemens; is a
shareholder in MHI Ventures; and has served on the board of trustees for the Society of Cardiovascular Angiography and In-
terventions. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received February 17, 2019; revised manuscript received March 26, 2019, accepted April 2, 2019.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019 Xenogiannis et al. 1637
SEPTEMBER 9, 2019:1635–49 Cardiac Catheterization in Prior CABG Patients

rate of progression of SVG lesions affects ABBREVIATIONS

HIGHLIGHTS
 Additional revascularization is often
needed after coronary artery bypass graft
surgery and carries increased risk.
AND ACRONYMS
the utility of physiological assessment in
deciding to defer revascularization, and more
BMS = bare-metal stents
data are warranted to determine the utility of
CABG = coronary artery bypass
physiological assessment (11–14).
graft surgery

 Optimal saphenous vein graft percuta- INTERMEDIATE SVG LESIONS

CI = confidence interval

neous coronary intervention requires CTO = chronic total occlusion

embolic protection devices and
vasodilators.
 If feasible, recanalization of the native
coronary artery is preferred over bypass
graft recanalization.
 Novel technical developments and phar-
As mentioned in the preceding text, in DAPT = dual-antiplatelet
therapy
contrast to native coronary artery lesions,
DES = drug-eluting stents
intermediate SVG lesions have high rates of
EPD = embolic protection
progression, which limits the value of physi-
device
ological assessment in this lesion subgroup.
FFR = fractional flow reserve
Despite promising early results with prophy-
lactic stenting of such lesions in the VELETI
IMA = internal mammary artery

macotherapy are needed to improve
outcomes after coronary bypass graft
surgery.
reviews of mainly observational studies have sug-
gested similar success with radial and femoral access,
in the RADIAL CABG (RADIAL Versus Femoral Access
for Coronary Artery Bypass Graft Angiography and
Intervention) trial, diagnostic coronary angiography
via radial access was associated with a higher mean
contrast volume (142
39 ml vs. 171
72 ml; p < 0.01),
longer procedure time (21.9
6.8 min vs. 34.2

14.7 min; p < 0.01), greater patient air kerma radiation
exposure (1.08
0.54 Gray vs. 1.29
0.67 Gray; p ¼
0.06), and higher operator radiation dose (first oper-
ator 1.3
1.0 mrem vs. 2.6
1.7 mrem; p < 0.01) but
higher patient satisfaction as compared with femoral
access (4). In observational studies, however, radial
access was associated with fewer vascular complica-
tions, and reduced hospital stay (4–6). If radial access
is selected, the left radial artery should be used in
most cases to facilitate engagement of the left inter-
nal mammary artery (LIMA) and the other bypass
grafts. When graft engagement is challenging using
radial access, early conversion to femoral access
should be considered (7).
PHYSIOLOGICAL ASSESSMENT OF SVGs
Although fractional flow reserve (FFR) measurement
is the standard of care for assessing intermediate
native coronary artery lesions, its use in SVG lesions
has been controversial (Table 1) (8–10) and is subject
to important limitations. First, FFR of a SVG is the
result of SVG flow, flow through the native coronary
artery (unless the latter is occluded), and flow via
collateral vessels; hence, FFR may be normal, even
when a SVG has severe stenosis. Second, the variable
(Moderate VEin Graft LEsion Stenting With
LIMA = left internal mammary
artery
the Taxus Stent and Intravascular Ultra-
MACE = major adverse cardiac
sound) trial, the larger VELETI II trial did not events
show any improvement of clinical outcomes MI = myocardial infarction
with stenting of intermediate SVG lesions as
OR = odds ratio
compared with medical therapy alone during
PCI = percutaneous coronary
3-year follow-up (12–14). In addition to the intervention
2 currently proven treatments to prevent SVG SVG = saphenous vein grafts
failure (aspirin and statins [15–18]), intensive
low-density cholesterol lowering with Proprotein
convertase subtilisin/kexin type 9 (PCSK9) inhibitors
holds promise for preventing progression of SVG
atherosclerosis and is currently being investigated for
slowing the progression of intermediate SVG lesions
(Alirocumab for Stopping Atherosclerosis Progression
in Saphenous Vein Grafts [ASAP-SVG]; NCT03542110).
PREVENTION AND TREATMENT OF
DISTAL EMBOLIZATION DURING SVG PCI
SVG PCIs represent approximately 6% of all PCIs
performed in the United States (2,19). The 2 key lim-
itations of SVG PCI are: 1) distal embolization and no
reflow in the acute phase; and 2) high rates of reste-
nosis and/or SVG disease progression during
follow-up.
SVG PCI has high risk for no reflow, likely due to
embolization of atheromatous material to the distal
vasculature and intense vasospasm caused by
microembolization of platelet-rich thrombi that
release vasoactive agents resulting in microvascular
obstruction (1,20). No reflow during SVG PCI has been
associated with high risk of subsequent adverse car-
diac events. Hong et al. (21) demonstrated that
compared with patients who did not develop no
reflow, those who did had higher risk for myocardial
infarction (MI) (14.36% vs. 55.2%; p ¼ 0.036) and
death (13.33% vs. 52.19%; p ¼ 0.039) during 5-year
follow-up.
1638 Xenogiannis et al.
Cardiac Catheterization in Prior CABG Patients
F I G U R E 1 Progression of Coronary Artery Disease in Patients With Prior CABG
(A) Causes of angina in patients with prior CABG. (B) PCI target vessel in prior CABG patients during different time intervals from CABG. Image in B reproduced with
permission from Brilakis et al. (2). CABG ¼ coronary artery bypass graft surgery; NCDR ¼ National Cardiovascular Data Registry; PCI ¼ percutaneous coronary
intervention; pts ¼ patients; SVG ¼ saphenous vein grafts.
Several strategies can be used to reduce the risk of
distal embolization and no reflow (Figure 2). The only
strategy that has been tested in randomized controlled
trials is use of embolic protection devices. Other
strategies include vasodilator administration, direct
stenting (22), and use of undersized stents (23).
Nicardipine is often preferred due to prolonged dura-
tion of action and less hypotensive effect and is often
administered both before and after PCI. Other phar-
macological agents such as adenosine, nitroprusside,
and verapamil have also shown to prevent or improve
no reflow events after intragraft administration
(24–31). By contrast, platelet glycoprotein IIb/IIIa re-
ceptor inhibitors can cause harm during SVG inter-
vention and should not be used routinely in SVG PCI
(32). Laser may result in “vaporization” of thrombus
and plaque components, potentially reducing the
risk for distal embolization; however, it may lead to
perforation, especially in highly angulated SVGs (33).
The only currently available embolic protection
devices (EPDs) are filters: the FilterWire (Boston Sci-
entific, Natick, Massachusetts) and the Spider (Med-
tronic, Santa Rosa, California) (Table 2) (34–40). Both
require a distal landing zone for deployment; hence,
they cannot be used in distal anastomotic lesions
(unless the filter is deployed in the native coronary
artery). The FilterWire is directly advanced through
the target SVG lesion, whereas the Spider can be
delivered over any guidewire advanced through the
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019
SEPTEMBER 9, 2019:1635–49
SVG lesion. A proximal occlusion device (Proxis, St.
Jude Medical, Saint Paul, Minnesota) was dis-
continued in 2012, and a distal occlusion device
(Guardwire, Medtronic) was discontinued in 2017.
In the first randomized controlled trial of EPD
versus no EPD for SVG (SAFER [Saphenous vein graft
Angioplasty Free of Emboli Randomized] trial) that
randomized 801 patients, use of the Guardwire was
associated with lower incidence of MI (8.6% vs.
14.7%; p ¼ 0.008) and “no reflow” (3% vs. 9%; p ¼ 0.02)
(36). Given the results of the SAFER trial, subsequent
EPD trials in SVG PCI compared one device with
another. The FIRE (FilterWire EX Randomized
Evaluation) trial compared the FilterWire with the
GuardWire in 651 patients undergoing SVG-PCI. Thir-
ty-day major adverse cardiac events (MACE) rates
were similar between the 2 groups (9.9% of FilterWire
EX group vs. 11.6% of GuardWire group; p ¼ 0.0008 for
noninferiority) (35). In the SPIDER (Saphenous vein
graft Protection In a Distal Embolic protection Ran-
domized) trial, the SpideRX filter was compared with
FilterWire and GuardWire in 700 patients and was
shown to be noninferior with comparable 30-day
MACE rates (9.1% vs. 8.4%; p ¼ 0.01 for non-
inferiority) (34). In a pooled analysis of 5 controlled
trials and 1 registry evaluating EPDs in SVG-PCI,
Coolong et al. (41) showed that the benefit of EPDs
for reducing 30-day MACE was consistent across
various degrees of SVG degeneration scores.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019 Xenogiannis et al. 1639
SEPTEMBER 9, 2019:1635–49 Cardiac Catheterization in Prior CABG Patients

C ENTR AL I LL U STRA T I O N Cardiac Catheterization in Patients With Prior CABG: A Systematic Approach

Xenogiannis, I. et al. J Am Coll Cardiol Intv. 2019;12(17):1635–49.

BMS ¼ bare-metal stents; CABG ¼ coronary artery bypass graft surgery; DAPT ¼ dual-antiplatelet therapy; DES ¼ drug-eluting stents; IMA ¼ internal
mammary artery; POBA ¼ plain old balloon angioplasty; SVG ¼ saphenous vein grafts.
1640 Xenogiannis et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019

Cardiac Catheterization in Prior CABG Patients SEPTEMBER 9, 2019:1635–49

T A B L E 1 Published Studies on Bypass Graft Physiological Assessment

First Author (Year) (Ref. #) Number of Patients Objective Major Findings

Aqel et al. (2008) (9)
Di Serafino et al. (2013) (10)
Almomani et al. (2018) (8)
10 patients with 10 SVG
lesions with >50%
stenosis
233 patients with CABG and
intermediate graft lesions
(venous and arterial)
33 patients with SVG lesions
vs. 532 patients with
native vessel disease
Access the physiological
significance of SVG lesions
with FFR
Compare the outcomes
between FFR-guided and
angiography-guided PCI
Compare the prognostic value
of deferring intervention
in lesions with FFR >0.8 in
native coronary artery
lesions vs. aortocoronary
bypass grafts
The sensitivity, specificity, PPV, NPV, and
accuracy of FFR <0.75 for the detection
of ischemia on stress MPI were 50%,
75%, 33%, 85%, and 70%, respectively
Patients with arterial graft stenosis had lower
rates of MACE and TVF in the FFR-guided
group. Patients with SVG stenosis had no
significant difference for both MACE and
TVF between the 2 groups
MACE and TVF rates were significantly higher
in the SVG group vs. the native vessel
group (36% vs. 21%; p ¼ 0.01 and 27%
vs. 14%; p ¼ 0.01)

CABG ¼ coronary artery bypass surgery; FFR ¼ fractional flow reserve; MACE¼ major adverse cardiac events; MPI ¼ myocardial perfusion imaging; NPV ¼ negative predictive
value; PCI ¼ percutaneous intervention; PPV ¼ positive predictive value; SVG ¼ saphenous vein graft; TVF ¼ target vessel failure.

Despite the aforementioned trials and the Amer-
ican College of Cardiology/American Heart Associa-
tion guideline recommendation to use EPDs in SVG
PCI when technically feasible (Class I, Level of Evi-
dence: B), EPDs remain underused: they were used in
only 22% of patients undergoing SVG PCI in the
United States (42–44) and in an even lower proportion
in other countries, likely due to concerns over cost,
F I G U R E 2 Strategies to Prevent Distal Embolization During SVG PCI
prolongation of the procedure, and lack of expertise
in use of those devices. The 2018 European Society of
Cardiology/European Association for Cardio-Thoracic
Surgery (ESC/EACTS) changed the EPD recommen-
dation to Class IIa (Level of Evidence: B) from Class I
(Level of Evidence: B) (45), referencing observational
studies that did not find an association between EPD
use and improved clinical outcomes (46,47). Howev-
er, observational studies comparing EPD use versus
no EPD use are subject to significant selection bias
(higher risk lesions are more likely to be treated with
an EPD), therefore their impact on clinical practice
should be limited. Prospective, randomized trials of
EPDs in SVG PCI would be optimal, but are unlikely to
be performed. EPDs may not be required for in-stent
restenotic lesions that have low risk for distal embo-
lization (48). Recurrent SVG in-stent restenosis may
respond to brachytherapy (49).

STENT SELECTION IN SVG PCI

Saphenous vein graft lesions have high rates of in-

stent restenosis, which often presents as an acute
coronary syndrome (50–52). Whether drug-eluting
stents (DES) improve outcomes compared with bare-
metal stents (BMS) in SVG lesions has been
examined in 6 prospective randomized trials (Table 3)
(50–59). During long-term follow-up, the 2 larger
studies showed no difference between DES and BMS
(54,56), and another showed worse outcomes with
DES (59). In a meta-analysis of the 6 previously
mentioned randomized trials by Kheiri et al. (60),
there were no significant differences between DES
and BMS in the long-term incidence of MACE, target
EPD ¼ embolic protection devices; IC ¼ intracoronary; SVG ¼ saphenous vein grafts. lesion revascularization, target vessel revasculariza-
tion, stent thrombosis, and all-cause mortality.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019 Xenogiannis et al. 1641
SEPTEMBER 9, 2019:1635–49 Cardiac Catheterization in Prior CABG Patients

T A B L E 2 Published Trials of EPDs in SVG Interventions

Study (Ref. #) Year Number of Cases Primary Endpoint

EPD Event Control Group p Value
EPD vs. No EPD Rate (%) Event Rate (%) Superiority

SAFER (37) 2002 801 30-day composite of death, MI, (Guardwire) 9.6 16.5 0.004
emergency CABG, or TLR

Test EPD Event Control EPD p Value

EPD vs. Another EPD Rate (%) Event Rate (%) Noninferiority

FIRE (35) 2003 651 30-day composite of death, (Filterwire) 9.9 (Guardwire) 11.6 0.0008
MI or TVR
SPIDER (presented at 2005 732 30-day composite of death, (Spider) 9.1 (Guardwire 24% or 0.012
the 2005 TCT meeting) MI, urgent CABG, or TVR Filterwire 76%) 8.4
PRIDE (37) 2005 631 30-day composite of cardiac death, (Triactiv) 11.2 (Filterwire) 10.1 0.02
MI, or TLR
CAPTIVE (38) 2006 652 30-day composite of death, (Cardioshield) 11.4 (Guardwire) 9.1 0.057
MI, or TVR
PROXIMAL (40) 2007 594 30-day composite of death, (Proxis) 9.2 (Guardwire 19% or 0.006
MI, or TVR Filterwire 81%) 10.0
AMETHYST (39) 2008 797 30-day composite of death, (Interceptor Plus) 8.0 (Guardwire 72% or 0.025
MI, or urgent repeat revascularization Filterwire 18%) 7.3

Triactiv is manufactured by Kensey Nash Corp. (West Whiteland Township, Pennsylvania), Cardioshield by MedNova (Galway, Ireland), and Interceptor Plus by Medtronic; other devices as in the text.
AMETHYST ¼ Assessment of the Medtronic AVE Interceptor Saphenous Vein Graft Filter System; CAPTIVE ¼ CardioShield Application Protects during Transluminal Intervention of Vein grafts by reducing
Emboli; EPD ¼ embolic protection device; FIRE ¼ FilterWire EX Randomized Evaluation; MI ¼ myocardial infarction; PRIDE ¼ Protection During Saphenous Vein Graft Intervention to Prevent Distal
Embolization; PROXIMAL ¼ Proximal Protection During Saphenous Vein Graft Intervention; SAFER ¼ Saphenous vein graft Angioplasty Free of Emboli Randomized; SPIDER ¼ Saphenous Vein Graft Protection
In a Distal Embolic Protection Randomized Trial; TLR ¼ target lesion revascularization; TVR ¼ target vessel revascularization; other abbreviations as in Table 1.

Because BMS and DES provide similar outcomes in
SVGs, BMS should be preferred in countries with
significant difference in the prices of DES and BMS.
There are several potential explanations for the
failure of DES to improve outcomes as compared
with BMS. First, the pathophysiology and physical
history of SVG disease differs from that of native
coronary arteries. Whereas atherosclerosis in coro-
nary arteries takes decades to develop, accelerated
atherosclerosis is observed in SVGs within months to
years, often in a more concentric and diffuse
pattern with less well-defined fibrous cap that
likely responds differently to DES. Second, neo-
atherosclerosis occurs earlier in DES compared with

T A B L E 3 Randomized Controlled Trials of DES Versus BMS in SVG Lesions

Year Drug-Eluting Stent Bare-Metal Stent

Study (Ref. #) Published N Primary Endpoint Event Rate (%) Event Rate (%) p Value

RRISC (52,59) 2006 75 6-month angiographic restenosis 13.6 32.6 0.031

2007 MACE at 32 months 58 41 0.130
SOS (50,55) 2009 80 12-month angiographic restenosis 9 51 <0.001
2010 80 Target vessel failure at 35 months 34 72 0.001
ISAR-CABG (56,57) 2011 610 12-month composite of death, MI, and TLR 15 22 0.02
2018 610 60-month composite of death, MI, and TLR 55.5 53.6 0.89
DIVA (54) 2018 597 12-month composite of cardiac death, target- 17 19 0.70
vessel MI, and TVR
2018 597 2.7-yr median follow-up—composite of cardiac 37 34 0.44
death, target-vessel MI, and TVR
ADEPT (53) 2018 57 Late lumen loss at 6 months 0.47
0.95 mm 0.53
1.09 mm 0.86
Presented
BASKET-SAVAGE* 2016 173 12-month composite of cardiac death, MI, and 2.3 17.9 <0.001
TVR
BASKET-SAVAGE* 2016 173 36-month composite of cardiac death, MI, and 12.4 29.8 0.0012
TVR

*Presented at the 2016 European Society of Cardiology meeting (Rome, Italy, August 30, 2016).
ADEPT ¼ Comparison between the STENTYS self-apposing bare metal and paclitaxel-eluting coronary stents for the treatment of saphenous vein grafts; BASKET-SAVAGE ¼ Basel Kosten Effektivitäts Trial–
SAphenous Venous Graft Angioplasty Using Glycoprotein 2b/3a Receptor Inhibitors and Drug-Eluting Stents trial; BMS ¼ bare-metal stents; DES ¼ drug-eluting stents; DIVA ¼ Drug-Eluting Stents vs. Bare
Metal Stents In Saphenous Vein graft Angioplasty; ISAR-CABG ¼ Is Drug-Eluting-Stenting Associated with Improved Results in Coronary Artery Bypass Grafts? trial; RRISC ¼ Reduction of Restenosis In
Saphenous vein grafts with Cypher sirolimus-eluting stent trial; SOS ¼ Stenting Of Saphenous vein grafts trial; other abbreviations as in Tables 1 and 2.
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Cardiac Catheterization in Prior CABG Patients SEPTEMBER 9, 2019:1635–49

F I G U R E 3 SVG Morphologies

(A) Anatomic variants of the proximal cap of occluded saphenous vein grafts (SVGs): retrograde crossing should not be attempted in
morphology #1 due to increased risk for perforation. (B) Anatomic variants of bypass graft distal anastomoses. Retrograde guidewire and
equipment crossing is more likely to be challenging for morphology #3.

BMS, which may lead to a catch-up phenomenon
(61,62). Third, thin-strut BMS may have lower risk
for restenosis in SVGs than thicker strut stents that
were used in most prior studies. Fourth, most DES
versus BMS studies had mandatory angiography
follow-up and were not blinded (50,52,53,57), which
may bias outcomes in favor of DES (oculostenotic
reflex). The DIVA (Drug-Eluting Stents vs. Bare Metal
Stents In Saphenous Vein Graft Angioplasty) trial,
the more recent randomized controlled trial that
demonstrated no benefit of DES over BMS used
blinding and did not mandate routine angiographic
follow-up (54).
EARLY POST-OPERATIVE GRAFT FAILURE,
ACUTE AND CHRONIC TOTAL SVG OCCLUSIONS
Graft failure during the early post-operative period
occurs in up to 12% of the grafts, with approximately
3% of the patients developing symptoms (63). Graft
occlusion rates are higher for vein grafts (3% to 12%
before discharge) compared with radial artery (3% to
4%) and internal mammary artery (IMA) (1% to 2.5%)
grafts (64). Potential causes include conduit defects,
suboptimal anastomosis technique, poor native
vessel runoff, and competitive flow with the native
vessel.
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SEPTEMBER 9, 2019:1635–49
F I G U R E 4 Proposed Algorithm for the Selection of Target Vessel for PCI in Patients With Prior CABG
LAD ¼ left anterior descending coronary artery; LIMA ¼ left internal mammary artery; other abbreviations as in Figures 1 and 2.
Graft patency is higher when anastomosed to
highly stenosed native coronary arteries: in a study of
164 patients who underwent pre-CABG FFR, graft
occlusion at coronary angiography after 1 year was
8.9% for bypass grafts on functionally significant le-
sions (FFR <0.75) versus 21.4% for bypass grafts on
lesions with FFR $0.75 (65). Conversely, there is an
accelerated rate of disease progression in bypassed
native coronary vessels, especially for non-left ante-
rior descending artery vessels and when SVGs are
used as compared with arterial grafts (66).
Unless the diagnosis of acute graft failure is made
in the operating room, PCI is preferred for symp-
tomatic graft failure. PCI is best performed in the
corresponding native coronary artery instead of the
bypass graft, if possible, in part because PCI of the
graft anastomosis may lead to suture dehiscence and
perforation (45). Redo CABG is recommended when
coronary anatomy is not suitable for PCI, a large ter-
ritory of myocardium is under jeopardy, multiple
significant grafts are occluded, or in case of anasto-
motic lesions (46,67).
Acute SVG occlusions carry a high risk for short-
and long-term adverse outcomes. Welsh et al. (68)
demonstrated that prior CABG patients presenting
Xenogiannis et al. 1643
Cardiac Catheterization in Prior CABG Patients
with an ST-segment elevation myocardial infarction
had similar outcomes compared with patients
without prior CABG when the infarct-related artery
was a native coronary artery; however, 90-day mor-
tality was much higher in prior CABG patients whose
culprit vessel was a SVG (19% vs. 5.7%; p ¼ 0.05).
Thrombosed SVGs often have large thrombotic
burden which can be approached with thrombectomy
and use of embolic protection devices (69). Aspiration
thrombectomy is preferred over rheolytic thrombec-
tomy to minimize the risk for distal embolization and
adverse outcomes (70). Suction should be maintained
until removal of the aspiration thrombectomy cath-
eter from the guide catheter for optimal thrombus
retrieval and reduction of the systemic thromboem-
bolism risk. Occasionally, aspiration through a deeply
intubated guide catheter or guide catheter extension
(balloon-assisted deep intubation—BADI) may be
required for retrieval of very large thrombi. Use of
laser is another option for such patients, whereas
thrombolytic administration has been associated with
poor outcomes and is generally avoided (71).
ST-segment elevation myocardial infarction due to
SVG obstruction can be very challenging to treat.
Given the suboptimal results of thrombolytic therapy
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T A B L E 4 Major Studies Comparing Bypass Graft Versus Native Coronary Artery PCI

Bypass Native Coronary

First Author (Year) (Ref. #) N Endpoint Graft PCI Artery PCI p Value Comments

Meliga et al. (2007) (88) 24 3-yr incidence of 83.9% 81.8% NS

death, MI, TLR, and TVR
Tejada et al. (2009) (89) 91 1-yr MACE 15.1% 12.9% 0.8
Varghese et al. (2009) (84) 142 No reflow 35% 24% <0.001 After a mean follow-up of 2.5
1.1 yrs, both
groups of patients had similar incidence of
TIMI flow grade 3 80% 95% <0.001
MI, repeat PCI, and death.
Bundhoo et al. (2011) (86) 161 TVR 15% 4.9% 0.031 Mean follow-up: 13.5
4.8 months. Graft-
PCI was an independent predictor (HR:
MACE 21.6% 8.9% 0.048
3.73, 95% CI: 1.27 to 10.87; p ¼ 0.016) of
MACE.
Xanthopoulou et al. (2011) (90) 190 MACE 43.2% 19.6% <0.001 Medial follow-up of 28 months.
Cardiac death 19.3% 6.9% 0.008
Repeat revascularization 23.9% 12.7% 0.02
Brilakis et al. (2011) (2) 300,902 In-hospital mortality 1.4% 0.9% <0.001 The proportion of SVGs as PCI target vessels
increases after 5 yrs and even more after
10 yrs from CABG. SVG PCI was an
independent factor associated with
higher in-hospital mortality (HR: 1.20,
95% CI: 1.10 to 1.30; p < 0.001).
Brilakis et al. (2016) (1) 11,096 In-hospital mortality 1.79% 0.83% <0.001
5-yr mortality 24.39% 17.05% <0.001
Mavroudis et al. (2017) (87) 220 TVR 12.5% 3.6% 0.0004
Median survival 315 months 327 months 0.005

CI ¼ confidence interval; HR ¼ hazard ratio; NS ¼ nonsignificant; other abbreviations as in Tables 1, 2, and 3.

in occluded SVGs, PCI is the preferred reperfusion
modality (71). Sometimes, identifying and engaging
the grafts can be challenging, often requiring multiple
catheters or aortography that may delay reperfusion
(72). Use of embolic protection may be useful in such
cases, although irreversible injury may have already
occurred. SVG lesions are highly friable and rich in
thrombus, and carry high risk for no reflow. Throm-
bolysis In Myocardial Infarction (TIMI) flow grade 3
post-PCI is achieved less frequently in patients who
had SVG as the culprit vessel compared with patients
who had a native coronary artery as the culprit vessel,
and such patients had higher in-hospital and 30-day
mortality and 1-year MACE rates (73,74).
Because of high risk for restenosis, SVG CTOs
should generally not be recanalized (Class III indica-
tion, Level of Evidence: C) (42), unless no other
treatment options exist. Occluded SVGs can be used,
however, for retrograde crossing of the corresponding
native coronary artery if the occlusion morphology is
favorable (Figure 3).
LEFT INTERNAL MAMMARY ARTERY AND
ARTERIAL GRAFT PERCUTANEOUS
CORONARY INTERVENTION
PCI of arterial grafts and especially of the LIMA is
much less common than SVG PCI. The 2 main reasons
are the better rates of LIMA patency over SVGs and
possibly performance of redo CABG in cases of LIMA
failure (Figure 4). Redo CABG is generally avoided in
patients with a patent IMA graft to the left anterior
descending coronary artery (75).
There should be high threshold for performing PCI
through IMA grafts, given the high risk for ischemia
and complications. Straightening of a tortuous LIMA
during the advancement of guidewires and micro-
catheters may lead to pseudolesions (the so-called
“accordioning effect”), that can lead to flow
compromise and ischemia. Pseudolesions must be
differentiated from vasospasm and dissection.
Administration of intravenous vasodilators will be
ineffective in the presence of the pseudolesions,
which should correct with guidewire withdrawal (76).
Deep guide intubation and use of guide catheter ex-
tensions may lead to IMA dissection and/or perfora-
tion (77,78). Despite the aforementioned limitations,
PCI to IMA lesions has been associated with higher
rates of restoration of TIMI flow grade 3 and lower
rates of periprocedural complications compared with
SVG PCI (79). IMA anastomotic lesions may be best
treated with balloon angioplasty, whereas proximal
and mid-segment lesions are stented in most cases
(80). Gruberg et al. (81) analyzed 174 patients who
underwent PCI of 128 IMA anastomotic lesions and
found a higher need for repeat revascularization after
stenting (33%) as compared with balloon angioplasty
only (4.3%). Sharma et al. (82) also reported worse
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 12, NO. 17, 2019
SEPTEMBER 9, 2019:1635–49
outcomes with stenting compared with angioplasty
alone at the anastomotic site (25% vs. 4.2%; p ¼
0.006) in 288 patients with 311 IMA lesions.
In patients with IMA grafts, the proximal subcla-
vian artery should be evaluated, because severe le-
sions in this location could lead to coronary ischemia
and even acute coronary syndromes (83). Subclavian
artery stenting can be an effective treatment in such
cases.
NATIVE CORONARY ARTERY PCI IN
PRIOR CABG PATIENTS
Most PCIs (approximately two-thirds) performed in
prior CABG patients are in native coronary artery le-
sions (2,84). Native coronary artery lesions in prior
CABG patients are often complex, with high rates of
calcification, tortuosity, and CTOs. The bypass grafts
can often be used for retrograde crossing in such pa-
tients, although wiring upstream from the distal
anastomosis can be challenging (Figure 3). Shortened
guiding catheters are especially recommended for PCI
of the distal native vessels through the IMA and also
retrograde techniques. Advanced PCI techniques,
such as use of atherectomy and CTO PCI are, there-
fore, often needed (85). Nevertheless, outcomes
after native coronary artery PCI are better than out-
comes post-SVG PCI in multiple series (Table 4)
(1,2,84,86–90).
In patients presenting with SVG lesions, several
operators advocate treating the native coronary ar-
tery instead, given the high short- and long-term risks
of SVG PCI. The 2018 ESC/EACTS guidelines on
myocardial revascularization state that PCI to a native
vessel should be preferred over PCI of the bypass
graft (Class IIa, Level of Evidence: C) (45). Decision
making can be challenging, however, as the corre-
sponding native coronary artery lesions are often
complex to treat or even totally occluded (often
CTOs). One approach is to treat the native coronary
artery when it is simple or when both SVG PCI and
native coronary PCI are complex, and there is local
expertise in treating such lesions (Figure 4). This
could also be done in a staged manner: the culprit
SVG lesion is initially treated (especially for patients
presenting with acute coronary syndromes who have
complex native coronary artery lesions), followed by
PCI of the native coronary artery weeks or months
later (91). If the thrombosed SVG cannot be recanal-
ized, PCI of the native coronary artery can sometimes
be performed (92). Because SVGs that become
occluded due to thrombus have very high rates of
reocclusion, staged PCI of the corresponding native
Xenogiannis et al. 1645
Cardiac Catheterization in Prior CABG Patients
coronary artery should be considered after the initial
procedure. In such cases, stenting the distal SVG
anastomosis should be avoided, if possible, as it could
hinder subsequent treatment of the native coronary
vessel. This conceptually appealing approach will
need to be validated in clinical studies.
Remaining flow in the SVG after successful native
vessel PCI has been a source of concern because
competitive flow from the SVG can lead to native
stent thrombosis (93,94). Some operators advocate
routine SVG coiling after treating the native coronary
artery although robust data are missing (95).
COMPLICATIONS
Due to the need to engage and visualize the bypass
grafts (and the often high complexity of treated le-
sions) angiography and PCI in prior CABG patients
requires longer procedural and fluoroscopy time,
higher radiation dose, and larger volume of contrast
(96–98). As a result (and also because of worse base-
line renal function), the risk for contrast nephropathy
and possibly hemodialysis is increased in those pa-
tients who have had prior CABG compared with those
who have not (93,97,99).
Even though coronary perforations were previ-
ously considered to be “innocent” complications in
prior CABG patients due to pericardial adhesions
preventing formation of a pericardial effusion and
tamponade, it is now appreciated that they can be
lethal events. Coronary perforation in prior CABG
patients can lead to loculated hematomas resulting in
cardiac chamber compromise and hemodynamic
collapse (dry tamponade). In the OPEN-CTO (Out-
comes, Patient Health Status, and Efficiency in
Chronic Total Occlusion Hybrid Procedures) database,
the perforation rate in post-CABG patients was
approximately 7%. Four perforations that led to death
occurred in the 365 patients with prior CABG (1.1%)
(100). Such loculated effusions may require surgery
or computed tomography-guided drainage for
treatment. Prompt identification and treatment of
coronary or graft perforation is, therefore, critical in
prior CABG patients (101,102).
POST-PROCEDURAL ANTITHROMBOTIC THERAPY
Long-term dual-antiplatelet therapy (DAPT) is
conceptually appealing in prior CABG patients, as
they often have extensive, multilevel atherosclerotic
disease and high risk for subsequent adverse cardio-
vascular events. In a meta-analysis of 22 studies
comparing DAPT to aspirin alone following CABG,
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Cardiac Catheterization in Prior CABG Patients SEPTEMBER 9, 2019:1635–49

DAPT was associated with lower cardiovascular mor-
tality (odds ratio [OR]: 0.67; p ¼ 0.02) and a trend
toward lower all-cause mortality (OR: 0.78; p ¼ 0.08),
although there was no difference when the analysis
was confined to randomized controlled trials. SVG
occlusion up to 1 year after CABG was significantly
lower with DAPT overall (OR: 0.64; p < 0.01) and in
the subset of randomized controlled trials (OR: 0.58;
p < 0.01). Importantly, patients who were treated
with DAPT for >6 months had lower stroke rates (OR:
0.47; p ¼ 0.04) but higher incidence of major bleeding
(OR: 1.31; p ¼ 0.03) (103).
In another meta-analysis of
controlled trials, patients who received ticagrelor or
prasugrel in addition to aspirin had lower mortality
compared with patients taking clopidogrel and
aspirin (relative risk: 0.49; 95% confidence interval
[CI]: 0.33 to 0.71; p ¼ 0.0002), whereas there was no
significant difference when clopidogrel plus aspirin
was compared with aspirin monotherapy (104). In a
subanalysis of the PLATO (Platelet Inhibition and
Patient Outcomes) trial, the reduction of the primary
endpoint of cardiovascular death, MI, and stroke was
not statistically significant in post-CABG patients
(19.6% vs. 21.4%; adjusted hazard ratio: 0.91 [inter-
quartile range: 0.67 to 1.24]) (105). Large, randomized
trials are needed in order to clarify the usefulness of
DAPT in different clinical settings (acute coronary
syndromes vs. stable coronary artery disease) and the
optimal antiplatelet combination.
In a study of 603 patients who underwent SVG PCI,
those taking clopidogrel in addition to aspirin for
more than 2 years had lower rates of MI or death
during a 5-year follow-up after the cessation of clo-
pidogrel, compared with patients who were taking
clopidogrel for a shorter time period (106). In the
DAPT (Dual Antiplatelet Therapy) study, patients who
underwent SVG PCI had better outcomes with 30-
month versus 12-month DAPT (107,108). Administra-
tion of DAPT for a longer duration than is usually
recommended after native vessel PCI (generally
6 months for stable coronary disease and 1 year for
acute coronary events) in patients undergoing SVG
PCI, therefore, may be beneficial.
Whether anticoagulation can reduce bypass graft
failure and improve clinical outcomes after CABG re-
mains controversial. In a substudy of COMPASS
(Cardiovascular OutcoMes for People Using Anti-
9 randomized coagulation StrategieS) trial, the combination of
2.5 mg of rivaroxaban twice per day with aspirin did
not reduce the incidence of graft failure in patients
with prior CABG compared with aspirin administra-
tion alone (113 [9.1%] vs. 91 [8.0%]; OR: 1.13; 95% CI:
0.82 to 1.57; p ¼ 0.45). It also did not reduce the
composite endpoint of cardiovascular death, MI, and
stroke (12 [2.4%] vs. 16 [3.5%], hazard ratio: 0.69;
95% CI: 0.33 to 1.47; p ¼ 0.34) (109).
CONCLUSIONS
Prior CABG patients undergoing cardiac catheteriza-
tion have increased risk for complications and often
require complex procedures. Several new studies
have advanced our understanding of the optimal
approach to cardiac catheterization and PCI in these
high-risk patients.
ADDRESS FOR CORRESPONDENCE: Dr. Emmanouil
S. Brilakis, Minneapolis Heart Institute, 920 East 28th
Street #300, Minneapolis, Minnesota 55407. E-mail:
esbrilakis@gmail.com.

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KEY WORDS coronary artery bypass
grafting surgery, percutaneous coronary
intervention, revascularization
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